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Editorial

Laparoscopic hepatectomy in cirrhotic patients with
Laparoscopic hepatectomy in cirrhotic patients with
hepatocellular carcinoma: technical aspects and
hepatocellular carcinoma: technical aspects and
potential benefi tsfi ts
potential bene

Osamu Itano, Takuya Minagawa, Yuko Kitagawa
Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan

Address for correspondence:
Dr. Osamu Itano, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
E-mail: itano@z8.keio.jp
Received: 29-01-2015, Accepted: 03-03-2015

INTRODUCTION Since the late 1990s, laparoscopic surgery has gained
popularity, resulting in a paradigm shift in liver surgery.
Surgical procedures are considered more challenging in Laparoscopic hepatectomy is thought to be a less-invasive
cirrhotic patients with hepatocellular carcinoma (HCC) than in procedure than open hepatectomy. The benefits of
[6]
non-cirrhotic patients, because of the former’s high morbidity laparoscopic hepatectomy may be particularly advantageous
[1]
and mortality following surgery. In open liver surgery, for reducing intraoperative blood loss and retaining
the extremely long incision required for mobilization and postoperative ascites. In matched-paired comparative
resection of the liver can result in significant intraoperative studies and a comprehensive meta-analysis, laparoscopic
blood loss or postoperative intractable ascites, followed hepatectomy was found to have several perioperative
by reduced collateral circulation in the abdominal wall and advantages with no differences in oncological outcomes. [7-11]
ligaments around the liver. These complications may progress Recent technological advances and accumulation of surgical
to postoperative hepatic failure in some patients. [2] experience have gradually expanded the indications for
laparoscopic hepatectomy to include treatment for HCC.
Innovations in technology and surgical skills for hepatectomy Laparoscopic hepatectomy has now been performed even
have been applied to minimize postoperative complications. in cirrhotic patients with HCC. There are several tips and
Some of these are as follows: (1) sophisticated instruments techniques for safely performing laparoscopic resection on
for liver transection, such as ultrasonic aspirators and the cirrhotic liver, as described below.
high-energy devices; (2) inflow and outflow vascular
control, such as inflow occlusion of the portal triad (Pringle LAPAROSCOPIC LIVER MOBILIZATION
maneuver), selective hepatic vascular occlusion, and total
hepatic vascular exclusion; (3) an anterior approach without We strongly recommend laterally dissecting the coronary
[3]
liver mobilization in order to prevent liver compression and triangular ligaments, after identifying the supra-hepatic
[12]
and tumor rupture; and (4) a liver-hanging maneuver to inferior vena cava (IVC) (“medial-to-lateral approach”).
[4]
minimize bleeding in the deeper parenchymal plane and to Dissection of the cranial ligamentous attachment using the
guide the direction of the parenchymal transaction. [5] medial-to-lateral approach helps avoid injuries to the IVC
and hepatic veins as well as to potential collateral vessels
at the lateral edges of the triangular ligament, which can
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Quick Response Code be difficult to control in some cirrhotic patients. Achieving
Website: careful ligation of the short hepatic veins with sealing
http://www.hrjournal.net/ devices and/or clips under a clear vision is essential for liver
mobilization. Surgeons need to utilize gravity and retraction
DOI: effectively to provide a clear view and avoid blind procedures.
10.4103/2394-5079.153786 Moreover, after the surgeon acquires adequate experience
with the technique, laparoscopic liver mobilization provides

6 Hepatoma Research | Volume 1 | Issue 1 | April 15, 2015